What causes depression and anxiety? I have been a practicing psychologist and psychoanalyst for almost 40 years and have seen hundreds of patients suffering from both. In my experience, some factors are obvious. People who suffer from depression and anxiety have experienced stresses and traumas in their development that predispose them to mood disorders. Garden-variety psychodynamic theory teaches us that issues involving loss, neglect, guilt, and rejection usually figure prominently in the backgrounds of people who present with significant symptoms of depression and anxiety.
In addition, over 50 years of research into the neurobiology of mood disorders strongly suggests that genetic and biological factors usually accompany, if not underlie these painful affective states. As a result of these assumptions, the treatment of depression today usually relies heavily on pharmacology, and drug companies have spent billions making sure this explanation is widely accepted. Some one in five US adults is taking at least one drug for a psychiatric problem; nearly one in four middle-aged women in the United States is taking antidepressants at any given time; and around one in 10 boys at American high schools are being given powerful stimulants to make them focus.
Since it's well known that psychological events produce biological changes, it remains debatable whether or not disorders of our biochemistry are causes or effects. What we do know is that untold amounts of money have been spent by the pharmaceutical industry to finance research and public relations designed to enshrine biochemistry and pharmacology as primary in the diagnosis and treatment of depression and anxiety.
However, what of the social, cultural and even political contexts that contribute to emotional suffering? We owe writer and journalist Johann Hari a great debt for illuminating these broader contextual factors in his new book, Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions. Hari first debunks the "received wisdom" that assumes the jury is in regarding the neurochemical basis of depression and the efficacy of antidepressants. He points to research based on the unpublished studies done by pharmaceutical companies on the efficacy of antidepressants, that almost unintentionally reveal a profound placebo effect underlying the clinical improvements reported. When depressed people who are being studied feel cared for by psychiatric researchers, they improve at astoundingly high rates (sometimes by as much as 40%). Thus, the pure biochemical antidepressant effect of these medications is much smaller than has commonly been assumed. In addition, when patients do get better, a commonly seen phenomenon, within a year at least half of them are again clinically depressed.
We have to acknowledge that some real people get better in real ways on antidepressants. However, it is also true that these benefits are less than advertised and results often diminish over time. Locating the cause of depression entirely in the brain and advocating a primarily pharmacological approach to its treatment is a paradigm with limited efficacy.
Hari argues that depression and anxiety should be considered two sides of the same coin. He asserts that everything that causes an increase in depression also causes an increase in anxiety, and the other way around. He points out that these two types of distress "rise and fall together." Again, this aligns with my own clinical experience treating patients with depression and anxiety: It's rare to see one without the other.
Most of Lost Connections presents the author’s account of the research done on the social and cultural causes of depression. For example, in the 1970s, British researchers George Brown and Tirril Harris and their team extensively interviewed 115 women living in a working-class suburb of London who were diagnosed with depression and compared their responses to a second group of 344 so-called normal—that is, not depressed—women from the same income group. Their findings were stunning at that time: The depressed women were three times more likely to have experienced certain major life stressors in the year prior to their diagnosis than the non-depressed women. The depressed women had more stressors, more trauma and fewer factors thought to provide psychological resilience, such as close friends and supportive extended family.
The notion that trauma and stressful life experience cause depression and anxiety is really no longer controversial. In the mid-1990s, Vincent Felitti of Kaiser Hospital in San Diego conducted an extraordinary and simple study, called the Adverse Childhood Experiences, or ACE Study. He sent out a questionnaire to 17,000 people who were seeking healthcare from Kaiser, asking people to check off which of 10 different categories of childhood trauma they had experienced. These traumas included most of the terrible things that can happen to you when you're a child, including various types of sexual, physical or emotional abuse. In addition, respondents filled out a detailed medical questionnaire testing for all sorts of things that could be problematic, such as obesity, addiction or depression. The results stunned even Dr. Felitti: For every category of traumatic experience someone went through as a child, that person was radically more likely to become depressed as an adult. The correlation was almost perfect: the greater the trauma, the greater the risk for depression, anxiety or suicide. For example, if you had six categories of traumatic events in your childhood, you were five times more likely to become depressed as an adult than someone who didn't have any. If you had seven types of traumatic events as a child, you were 3,100 percent more likely to attempt suicide as an adult.
The notion that depression isn't a disease, but a normal response to abnormal life experiences wouldn't surprise most of us, except for the fact that we live in a culture which pathologizes psychic suffering as a disorder within individuals, rather than as suffering that makes sense given a pathological environment. The cost of such victim blaming is high. If you believe = depression is solely a result of disordered brain chemistry, you don't have to think about your life and about what other people may have done to you. It's painful to think along these lines, which may be one of the reasons why a biological explanation is often easier. As Hari says, quoting Dr. Robert Anda who worked on the ACE study, "When people have these kinds of problems, it's time to stop asking what's wrong with them, and time to start asking what happened to them."
Hari believes that the social and cultural causes of depression all involve some form of "disconnection." He argues that people in our culture are disconnected from meaningful work, citing as evidence a huge Gallup poll about work conducted in 2011 and 2012 that included millions of workers across 142 countries. Gallup found that only 13% of people described themselves as "engaged" in their jobs, meaning that they were enthusiastic about and committed to their work and pleased with their contribution to their organization. Sixty-three percent reported themselves "not engaged" and 24% described themselves as "actively not engaged," which in this survey, meant that they acted out their unhappiness, undermining their coworkers and even seeking to damage the companies where they work. Nearly twice as many people hate their jobs as love their jobs. The prevalence of deadening, routinized and alienated work leads people to feel unappreciated, unrecognized and frustrated, with little or no sense of contributing to something bigger and better than themselves. Disempowerment and indifferent hierarchies at work cause depression.
Hari explores another form of disconnection that is more obvious, namely being disconnected from other people. Social isolation and loneliness have been shown to have a wide range of negative physical/health consequences. Feeling lonely causes our cortisol levels to soar, a hormonal outcome that causes wide-ranging damage to the body and mind. In fact, acute loneliness is seen as every bit as stressful as being physically attacked. Human beings are wired to be in groups, and when we are alone for too long, we feel alienated and insecure.
Loneliness and social isolation is increasingly a public health epidemic in America. As sociologist Robert Putnam has shown, the percentage of Americans actively involved in community organizations has radically declined. From 1985 to '95—just one decade—active involvement in community organizations decreased almost 50 percent. We seem to have stopped banding together and have found ourselves increasingly shut away in our own homes. We do things together less than any generation that came before us. And finally, we know that being alone changes our brains and that curing that loneliness changes our brains, so if we're not looking at social as well as biological factors, we can't understand what's really going on with depression today.
Hari goes on to talk about another form of disconnection: being disconnected from "meaningful values." In this section, he offers a critique of our consumer culture clearly dominated by an addiction to material possessions, money and status. He points out that advertising experts have admitted since the 1920s that their job is to make people feel inadequate and to then offer their products as the solution to the very inadequacy they have created. A capitalist economy and culture that tells us that there is never enough, and that we are never enough, provides us with what Hari calls "junk values." Materialism has never been associated with health and happiness. In fact, when people are asked to reflect on what really matters to them they usually admit to such deep values as meaningful work, community, family, or being a loving person in service to others. When we are estranged from ourselves, we suffer.
Hari also reviews some of the usual suspects that come up in any discussion about emotional well-being, including being disconnected from status, respect and social approval by virtue of the gross and radical imbalances of income and wealth in our society, as well as being disconnected from the natural world and animals in a society in which most people live in cities and conduct most of their lives indoors. There is powerful scientific evidence that suggests societies with greater equality have less psychiatric illness and that being out in nature reduces depression and anxiety.
Hari wants to be clear that he is not saying genetics and neurobiology have no effect on depression. What he is saying is that the brain and even our genes respond to signals from the world. When scanned, the brains of London cabdrivers who have to memorize the entire map of London, reveal that the part responsible for spatial awareness is bigger than in other people's brains. Experience changes the brain. Clearly, once changes in the brain have occurred, they gain a momentum of their own and contribute to, or reduce, emotional distress. Genes can significantly increase our sensitivity to environmental stress, but that's a far cry from saying that they are a primary cause of depression. Hari points out that historically depression and anxiety were regarded as moral failures, and as a result, the notion that depression is primarily biological can be seen as a defense against blame and judgment. However much such a defense may help some people fend off social disapproval and private shame, the question of causation isn't answered.
The importance of understanding the social and cultural conditions that seem to produce depression and anxiety is that it points the way toward interventions and social changes that could yield tremendous psychological benefits on a mass scale. Obviously, I'm a believer in psychotherapy and I've also repeatedly seen the short- and medium-term benefits of medications. However, to truly deal with the epidemic of depression and anxious suffering in the world we need to consider making more radical social and political changes. Reducing inequality is not merely in the interest of justice, but would likely produce a significant decrease in depression and anxiety. Further, experiments in cooperative, more democratic and egalitarian work arrangements have shown that such innovations, by reducing the alienation and estrangement people feel at work, can significantly decrease stress while not sacrificing success in the marketplace. Hari suggests we ask depressed people not “What's the matter with you?” but instead, “What matters to you?”
Such "solutions" involve making radical changes in social life. However, I think that our movement acquires a greater degree of urgency and validity if we understand how much emotional suffering can potentially be remediated. Such understanding can even inform political proposals like those that call for a universal basic income, or UBI, in which people are given a fixed amount of money every year, completely without conditions, to do with whatever they wish—something that has been tried experimentally in many places in the world. Such projects not only directly address the problem of poverty and income inequality, but emotional health and welfare as well. The UBI gives people the freedom to live and work in ways aligned with their deeper non-materialistic, non-junk values. They can hold out for work that is less alienated and more safely connect with their families and communities. The research into these experiments has shown that they greatly enhance the overall levels of emotional as well as physical well-being.
When we privilege explanations of depression and anxiety that emphasize our internal biology, we let society off the hook. We privatize psychological pain even as the role that our culture contributes to that pain goes unchallenged. Johan Hari’s new book helps us tell a different story. As Hari points out, it is even a story endorsed by the World Health Organization, the leading medical body in the world, which in 2011, summarized the evidence this way: "Mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as if individual, solutions.” In its official statement for World Health Day in 2017, the United Nations explained that "the dominant biomedical narrative of depression" is based on "biased and selective use of research outcomes" that "cause more harm than good, undermine the right to health, and must be abandoned."
Hari eloquently states this case in his last chapter, when he says: "You aren't a machine with broken parts. You are an animal whose needs are not being met. You need to have a community. You need to have meaningful values, not the junk values you've been pumped full of all your life, telling you happiness comes through money and buying objects. You need to have meaningful work. You need the natural world. You need to feel you are respected. You need a secure future. You need connections to all these things. You need to release any shame you might feel for having been mistreated.”
I think it's fair to say that in order to achieve these things, we need a revolution.